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Wiki US vs Measurments

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agbirm

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We seem to have differing opinions in our office when it comes to ultrasounds. In the case of codes like 76775, 76856 and 76857 do the measurements for some or all of the organs (depending on the code used) have to be documented? Is it ok if they only have documented that they have visualized these organs and have dictated the findings they see?
 
All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated. For those codes whose sole diagnostic goal is a biometric measure (ie, 76514, 76516, and 76519), permanently recorded images are not required. A final, written report should be issued for inclusion in the patient's medical record. The prescription form for the intraocular lens satisfies the written report requirement for 76519. For those anatomic regions that have "complete" and "limited" ultrasound codes, note the elements that comprise a "complete" exam. The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent).
 
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